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ZONING PERMIT APPLICATION www.countyofdane.com SUPPLEMENT to Web-App # <br /> PROPERTY OWNER INFORMATION CUSTOMER TO PROVIDE <br /> A OWNER NAME <br /> i..,..2„,' r t. Vie `� 7 144 ❑Zoning Status; CUP; <br /> OWNE' -DDRES' (Number,S eet,City,State,Zip) Deed Restriction; CSM <br /> Variance(# ) <br /> HOME PHONE CELL PHONE E-MAILADDRESS <br /> ❑Site Plan drawn to scale <br /> AGENT INFORMATION CONTRACTOR INFORMATION and includes dimensions <br /> AGENT NAME CONTRACTOR NAME <br /> y <br /> NI" S r(J e (, u e no ❑Site Plan including location <br /> AGENT ADDRESS CONTRACTOR ADDRESS of well/septic <br /> 103 P k e. tan e <br /> (City,State,Zip) 0. f '^ (City,State,Zip) ❑Setbacks <br /> PHONE V U U r,t ti VV-` n� . PHONE ❑Site Plan approval from <br /> h0$' 9O5-' 0 1O applicable township. <br /> E-MAILADD ESS E-MAILADDRESS <br /> R. �� ❑Floor plans to scale <br /> PROPERTY/LOCATION INFORMATION (http://accessdane.co.dane.wi.us/) <br /> ❑PARENT CEL NU�nE G ! - ore NTZONING/Q ACREAGE: <br /> Elevation of property <br /> ❑PARCEL O = •U frontage drawn to scale. <br /> le. <br /> NUMBER <br /> TOWNSHIP: SECTION: <br /> • (Am n 1/4: 1/41/4: ❑ Driveway permits <br /> ADDRESS: D �/ (state,county,town) <br /> ` I I`—� (_-41 —e <br /> 0 Sanitary permits <br /> CSM: LOT SUBDIVISION BLOCK/LOT <br /> (public,private) <br /> PROPOSED PROJECT INFORMATION STAFF REVIEW <br /> PROJECT DESCRIPTION: ' <br /> If Ot W IO1 A Of psY. 1 Z D J e/ ,-c._s_1.,�u�^rl,5 cd�, _9— SC2e✓kCaZoning District <br /> project is'a new building or structure. l(1 <br /> �""' D Permitted Use? <br /> ❑This project is an addition/alteration to an existing building or structure. <br /> SANITARY SE I E: PERMIT NUMBER: ❑ Rural Address <br /> R FIEPTIC (new/existing) <br /> HEIGHT IN FEET: NUMBER OF STORIES: (Not including basement) <br /> Li Wetland/Floodplain/ <br /> AREA TO NEAREST SQUARE FOOT: Shoreland (attachment) <br /> (Outside dimensions including unfinished area,attached garages and above grade decks or porches) <br /> BASEMENT: 1ST FLOOR: r---, <br /> ErosionControl permit <br /> / jl j TOTAL SQUARE FOOTAGE: j (slopes, disturbance, <br /> 'j filling/access) <br /> 2ND FLOOR: 3RD FLOOR: <br /> I +4 _ ❑ Review Location Survey <br /> ESTIMATED CONSTRUCTION COST: ♦ —Ii. —II. -10. and available options. <br /> (Please round to nearest dollar) $t <br /> 1. The property is within 300 feet of a stream or 1000 feet from a pond or lake? 4Yes ❑No ❑Don't know <br /> 2. Is there a wetland or floodplain on or near the property? ❑Yes do'l I o ['Don't know <br /> 3. Have you talked with the township about your project and are they in agreement? es /No <br /> 4. Has there been a zoning permit issued for this property in the past 5 years? ❑Yes ❑No <br /> 5. Is this project associated with a rezone/CUP/variance(petition/appeal# ) (leave blank if none) <br /> 6. Is a location survey required? (see reverse) ['Yes ❑No ❑Don't know <br /> 7. Is this to correct a violation? ['Yes ❑No <br /> APPLICATION MUST BE SIGNED <br /> (Continue on Back) —► —► —► <br /> 545-112(4/08) <br />